The Department of Surgery, University of Toronto, Toronto, Ont.
Can J Surg. 2013 Dec;56(6):393-7. doi: 10.1503/cjs.017412.
Operative reports (ORs) serve as the official documentation of surgical procedures. They are essential for optimal patient care, physician accountability and billing, and direction for clinical research and auditing. Nonstandardized narrative reports are often of poor quality and lacking in detail. We sought to audit the completeness of narrative inguinal hernia ORs.
A standardized checklist for inguinal hernia repair (IHR) comprising 33 variables was developed by consensus of 4 surgeons. Five high-volume IHR surgeons categorized items as essential, preferable or nonessential. We audited ORs for open IHR at 6 academic hospitals.
We audited 213 ORs, and we excluded 7 femoral hernia ORs. Tension-free repairs were the most common (82.5%), and the plug-and-patch technique was the most frequent (52.9%). Residents dictated 59% of ORs. Of 33 variables, 15 were considered essential and, on average, 10.8 ± 1.3 were included. Poorly reported elements included first occurrence versus recurrent repair (8.3%), small bowel viability in incarcerated hernias (10.7%) and occurrence of intraoperative complications (32.5%). Of 18 nonessential elements, deep vein thrombosis prophylaxis, preoperative antibiotics and urgency were reported in 1.9%, 11.7% and 24.3% of ORs, respectively. Repair-specific details were reported in 0 to 97.1% of ORs, including patch sutured to tubercle (55.1%) and location of plug (67.0%).
Completeness of IHR ORs varied with regards to essential and nonessential items but were generally incomplete, suggesting there is opportunity for improvement, including implementation of a standardized synoptic OR.
手术报告（OR）是手术过程的官方记录。它们对于提供最佳的患者护理、医生问责和计费、临床研究和审核方向至关重要。非标准化的叙述报告往往质量较差，缺乏细节。我们旨在审查叙述性腹股沟疝 OR 的完整性。
通过 4 位外科医生的共识，制定了一个包含 33 个变量的腹股沟疝修复（IHR）标准化检查表。5 位高容量 IHR 外科医生将项目分为必要、可取或非必要。我们在 6 家学术医院审查了开放 IHR 的 OR。
我们审查了 213 份 OR，排除了 7 份股疝 OR。无张力修复是最常见的（82.5%），Plug-and-Patch 技术最常见（52.9%）。住院医师口述了 59%的 OR。在 33 个变量中，有 15 个被认为是必要的，平均有 10.8±1.3 个变量被包括在内。报告较差的元素包括初次修复与复发性修复（8.3%）、嵌顿疝中小肠的活力（10.7%）和术中并发症的发生（32.5%）。在 18 个非必要元素中，深静脉血栓形成预防、术前抗生素和紧急情况分别在 1.9%、11.7%和 24.3%的 OR 中报告。修复特异性细节在 0 到 97.1%的 OR 中报告，包括补丁缝合到结节（55.1%）和塞子的位置（67.0%）。
IHR OR 在必要和非必要项目方面的完整性各不相同，但总体上不够完整，这表明有改进的空间，包括实施标准化的概要 OR。
